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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701101
Report Date: 09/27/2024
Date Signed: 10/15/2024 05:27:38 PM


Document Has Been Signed on 10/15/2024 05:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108



FACILITY NAME:KCE CHAMPIONS LLC AT HEARST ELEMENTARYFACILITY NUMBER:
376701101
ADMINISTRATOR:SAMUEL STAUGHNFACILITY TYPE:
840
ADDRESS:6230 DEL CERRO BOULEVARDTELEPHONE:
(916) 387-5761
CITY:SAN DIEGOSTATE: CAZIP CODE:
92120
CAPACITY:224CENSUS: 67DATE:
09/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Samuel StaughnTIME COMPLETED:
05:00 PM
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On 9/27/24 at 1:20PM Licensing Program Analyst (LPA) Patrick Ma conducted an unannounced visit to follow up on a self-reported incident that occurred on 6/25/24 where a child used a facility bathroom with an adult not associated with the child care program. No incident occurred between child and adult with only a quick salutation by the adult. LPA met with Director Samuel Staughn and had telephone contact with Jill Brown, Senior Licensing Compliance Advisor for Champions.

During the visit LPA interviewed Director and Ms. Brown over the phone. Incident occurred when Campions was running a local camp at Temple Emanue-EL at 6299 Capri Dr, San Diego, 92120 from 6/24/24 thru 8/19/24 and not at facility address. Director and Ms. Brown stated although the camp was local it was not affiliated with facility license. Camps that meet exemption regulations are not under child care licensing regulations. No violation was observed as incident occurred under exemption regulations.

LPA advised Director and Ms. Brown, in the future, facility will ensure proof of exemption (via camp certification) is available for CCL observation.

No deficiency was cited. See LIC 9102 for Technical Violation issued.

Exit interview conducted and report was reviewed with the facility representative Samuel Staughn. A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Renesha AskewTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Patrick MaTELEPHONE: (619) 767-2218
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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